Nokea
A patient with pericarditis has just been admitted to the CCU. The nurse planning the patients care should prioritize what nursing diagnosis?
- A. Anxiety related to pericarditis
- B. Acute pain related to pericarditis
- C. Ineffective tissue perfusion related to pericarditis
- D. Ineffective breathing pattern related to pericarditis
Correct Answer: B
Rationale: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.
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A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patients medication regimen, what nursing diagnosis should be prioritized?
- A. Risk for injury
- B. Risk for infection
- C. Risk for peripheral neurovascular dysfunction
- D. Risk for unstable blood glucose
Correct Answer: B
Rationale: Immunosuppressants decrease the bodys ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels.
A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patients symptoms, the nurse should teach the patient to do which of the following?
- A. Eat a high-protein, low-carbohydrate diet.
- B. Avoid activities that cause an increased heart rate.
- C. Avoid large crowds and public events.
- D. Perform deep breathing and coughing exercises.
Correct Answer: B
Rationale: Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary.
The nurse on the hospitals infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients. What classification of patients would be at greatest risk for hospital-acquired endocarditis?
- A. Hemodialysis patients
- B. Patients on immunoglobulins
- C. Patients who undergo intermittent urinary catheterization
- D. Children under the age of 12
Correct Answer: A
Rationale: Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis.
The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond?
- A. Azathioprine decreases the risk of thrombus formation.
- B. Azathioprine ensures adequate cardiac output.
- C. Azathioprine increases the number of white blood cells.
- D. Azathioprine minimizes rejection of the transplant.
Correct Answer: D
Rationale: After heart transplant, patients are constantly balancing the risk of rejection with the risk of infection. Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf), azathioprine (Imuran), or mycophenolate mofetil (CellCept), and corticosteroids (prednisone) to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance cardiac output, or increase white cell counts.
A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is particularly common among young people who appear otherwise healthy?
- A. Dilated cardiomyopathy (DCM)
- B. Arrhythmogenic right ventricular cardiomyopathy (ARVC)
- C. Hypertrophic cardiomyopathy (HCM)
- D. Restrictive or constrictive cardiomyopathy (RCM)
Correct Answer: C
Rationale: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.